95-101848Y
;
City of Federal Way
INIV-0APPLICATION
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PIMSE PRINT �� "
APPLICATION #:
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Tenant (if known) of
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State , Zi
Phone
Nature of Wo
Name (F,M,L) v
Address
City
Zip
Contact Person Day Phone
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Phone
Fax
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Company Name '
Address
City
State
Zip
Contact Person
Phone
Fax
Contractor's # (card must be presented)
Expiration Date
Verified - ❑ Yes ❑ No
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LEGAL DESCRIPTION
,Please Corrrirlete Reverse Sims
CD0492 (Rev 4193)
STRUCTURE
ExL .g Use
P, used Use
Permit includes:
❑ Building
❑ Plumbing Mechanical ❑ Other
Type of Work:- ❑ Residential
❑ New
Remodel ❑ Number of Units ❑ Deck
Commercial
❑ Addition
Garage ❑ Shed ❑ Other
Enter 1st Floor 411§sq ft
2nd Floor sq ft
3rd Floor sq ft Existing Floor Area sq ft
Area Basement- sq ft
Decks sq ft
Garage sq ft Proposed Total Area sq ft
Water vailability ❑ Sewer Availability ❑ On -Site Septic System Availability ❑ ..foec raiuttitnn'.°• : .t
Zoning
Lot Size
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Name
Address
City
State Zip
MECRANICALCONTRACTOR 71
Contractor Name
Address
City
State Zip
Contact
Phone Fax
License #
Expiration Date Verified ❑ Yes ❑ No .
LUMBING lC0N`T-R-`AC I TORi
Contractor Name
Address
City
State
Zip
Contact_
Phone
Fax
license #
Expiration Date Verified ❑ Yes ❑ No
Water Closets
Sinks
Urinals Lawn Sprinklers
Bathtubs
Dish Washers
Drinking Fountains Other
Showers
Electric Water Heaters
Sumps
Lavatories
Washing Machine
Drains Total Fig ttsre Coafatt
MECRANICAU
Fuel Type (electric/other)
Gas Dryer
Air Handling < = 10,000 CFM 15-30 Tons
Length of Gas Piping
Range
Air Handling > = 10,000 CFM 30-50 Tons
Furn <1OOK BTUs
Gas Log
Unit Heater, 50+ Tons
Furn > 100 BTUs
Fans
Miscellaneous Fuel Tanks
Gas Hwt
Hood
Boilers Above Ground
Conv Burner
Duct Work
0-3 Tons Underground
BBQ's
Wood Stoves
3-15 Tons Total Unit Count
DISCLAIMER: I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge and further that I am authorized by the owner
of the above premises to perform the work for which permit application is made. I further
agree to save harmless the City of Federal Way as to any claim (including costs, expenses,
and attorneys' fees incurred in investigation and defense of such claim), which may be
made by any person, including the undersigned, and filed against the City of Federal Way,
but only where such claim arises out of the reliance of
the City, including its officers
and employees, upon the accuracy of the information supplied to the City as a part of this
application.
Owner/Agent: